Debit Order Signup Form

Written Authority and Mandate for Debit Payment Instructions

A. Authority

* Given by (name of Accountholder)
* Address
* Contact telephone number
Fax number
* Email Address
* Bank
* Branch and Code
* Account Number
* Type of Account
* Date
Abbreviated Name as Registered with the Bank LUCIAN
Beneficiary’s Address PO BOX 950, KNYSNA, 6570, WESTERN CAPE

This signed Authority and Mandate refer to our contract dated (“the Agreement”).

I/We hereby authorise you to issue and deliver payment instructions to your Banker for collection against my/our above-mentioned account at my/our above-mentioned Bank (or any other bank or branch to which I/we may transfer my/our account) on condition that the sum of such payment instructions will never exceed my/our obligations as agreed to in the Agreement and commencing on and continuing until this Authority and Mandate are terminated by me/us by giving you notice in writing of not less than 20 ordinary working days, and sent by prepaid registered post or delivered to your address as indicated above. The individual payment instructions so authorised to be issued must be issued and delivered as follows: monthly

In the event that the payment day falls on a Sunday, or recognised South African public holiday, the payment day will automatically be the very next ordinary business day. Furthermore, if there are insufficient funds in my account to meet the obligation, you are entitled to track my account and represent the instruction for payment as soon as sufficient funds are available in my account. Payment Instructions due in December may be debited against my account on _____________. I/We understand that the withdrawals hereby authorised will be processed through a computerised system provided by the South African Banks. I also understand that the details of each withdrawal will be printed on my bank statement. Such must contain a number, which must be included in the said payment instruction and if provided to me should enable me to identify the Agreement. This number must be added to this form in Section E before the issuing of any payment instruction.

B. Mandate

I/We acknowledge that all payment instructions issued by you shall be treated by my/our abovementioned bank as if the instructions have been issued by me/us personally.

C. Cancellation

I/We agree that although this Authority and Mandate may be cancelled by me/us, such cancellation will not cancel the Agreement. I/We shall not be entitled to any refund of amounts which you have withdrawn while this Authority was in force if such amounts were legally owing to you.

D. Assignment

I/We acknowledge that this Authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party.

Signed at

on this of in

(Signature as used for operating on the account - sign below with your mouse)

Full names

E. Agreement Reference Number

This agreement reference number is CBS-YYYY-XXXX where YYYY is our current tax year, and XXXX is the invoice number. The full reference number will be visible on your bank statements when the debit order is taken.